APPLICATION FORMPROFESSIONAL CERTIFICATEIN YOUTH PSYCHIATRY

APPLICATION FORM

PROFESSIONAL CERTIFICATE

IN YOUTH PSYCHIATRY

Personal Details

First Name*

Surname*

Address*

Location*

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

New Zealand

International - Other

If International - other, please enter location here.

Preferred Contact Number*

Preferred Email Address*

Workplace*

Qualifications*

Role*

Psychiatry Trainee

Psychiatry Consultant

Other

If Role - other, please enter your role here.

AHPRA Registration Number*

(or equivalent international registration agency):

Other Qualifications: Please upload here.

If you do not have an AHPRA registration number, please provide evidence of your qualification as a psychiatrist or GP (e.g., registration with your national professional association or academic transcript).

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How did you hear about this course ?*

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